Intensidad de Terapia y Terapia Inducida Por Restricción_ Control 2

8/11/2019 Intensidad de Terapia y Terapia Inducida Por Restriccin_ Control 2

1/19

Evidence-Based Systematic Review:Effects of Intensity of Treatment

and Constraint-Induced LanguageTherapy for Individuals WithStroke-Induced Aphasia

Purpose: This systematic review summarizes evidence for intensity of treatment andconstraint-induced language therapy (CILT) on measures of language impairment andcommunication activity/participation in individuals with stroke-induced aphasia.Method:A systematic search of the aphasia literature using 15 electronic databases(e.g., PubMed, CINAHL) identified 10 studies meeting inclusion/exclusion criteria. Areview panel evaluated studies for methodological quality. Studies were characterizedby research stage (i.e., discovery, efficacy, effectiveness, costbenefit/public policyresearch), and effect sizes (ESs) were calculated wherever possible.Results:In chronic aphasia, studies provided modest evidence for more intensivetreatment and the positive effects of CILT. In acute aphasia, 1 study evaluatedhigh-intensity treatment positively; no studies examined CILT. Four studies reporteddiscovery research,with quality scores ranging from 3 to 6 of 8 possible markers. Fivetreatment efficacy studieshad quality scores ranging from 5 to 7 of 9 possible markers.

One study of treatment effectiveness received a score of 4 of 8 possible markers.Conclusion:Although modest evidence exists for more intensive treatment and CILT forindividualswith stroke-inducedaphasia, theresults of this reviewshouldbe consideredpreliminary and, when making treatment decisions, should be used in conjunction

with clinical expertise and the clients individual values.

KEY WORDS: aphasia, intensity, constraint, rehabilitation

Constraint-induced language therapy (CILT), a relatively new apha-sia treatment, (Pulvermuller et al., 2001), has garnered consid-erable interest from consumer groups and clients with aphasia.The major components of CILT involve both forced use of verbal languageand massed practice (i.e., high intensity of treatment). Both are of con-

siderable importance in light of recent work in neuroscience demonstrat-

ing that the neuroplasticity of the adult brain can be impacted by several

experience-dependent principles, including intensity of training and forced

use of cognitive capacities (Kleim & Jones, 2008). Because intensity of

treatment is an important variable that affects neuroplasticity, any dis-

cussion of CILT must consider the impact not only of constraint but also

of treatment intensity on outcomes. Therefore, the aim of this evidence-

based systematic review (EBSR) was to examine the current state of the

evidence that used one or both principles of CILT for individuals with

stroke-induced aphasia: (a) constraining treatment responses to the verbal

Leora R. Cherney

Rehabilitation Institute of Chicago, IL

Janet P. PattersonCalifornia State University,

East Bay, Hayward, CA

Anastasia RaymerOld Dominion University, Norfolk, VA

Tobi FrymarkTracy Schooling

American Speech-Language-HearingAssociation, Rockville, MD

Journal of Speech, Language, and Hearing Research Vol. 51 12821299 October 2008 DAmerican Speech-Language-Hearing Association1092-4388/08/5105-1282

1282


2/19

modality only and (b) providing treatment on an inten-

sive delivery schedule.

The neurobiological principles and rehabilitation

techniques surrounding CILT were derived from animal

studies (Taub, 1977) as well as from a series of investi-

gations of limb movements in patients with chronic stroke

and hemiplegia (Taub, Miller, Novack, & Cook, 1993; Taub

& Wolf, 1997). These studies found that motor behavior ofan impaired limb was modifiable with intensive practice

over a short period of time. The techniques collectively

known asconstraint-induced movement therapy (CIMT)

involve restraining the use of the less affected arm for

themajority of wakinghoursto counteract thepresumed

learned nonuse of the affected arm. Repetitive training

and shaping of movementsof the affected arm take place

in intensive treatment (6 hr per day) over 2 consecutive

weeks.

In the past 20 years, a large body of evidence, ap-

plying either the original CIMT technique or a variant of

this approach, has accumulated in support of the efficacyof constraint-induced (CI) therapy for rehabilitating

hemiparetic arm use in individuals with chronic stroke

(Hakkennes & Keating, 2005; Taub, Uswatte, & Piclikiti,

1999). To date, there are more than 120 published stud-

ies, including a single-site, placebo-controlled trial (Taub

et al., 2006) and a large multisite randomized trial (Wolf

et al., 2006). Although the magnitude of the treatment

effects have varied throughout the CIMT literature, the

generally positive outcomes have encouraged investigators

to examine the effects of CI and their potential benefits in

otherdomains of strokerehabilitation, including aphasia.

Since being introduced to the field of aphasiology byPulvermuller and colleagues (2001), CILT has been met

with great interest. Pulvermuller et al. argued that pa-

tients with aphasia often use the communication chan-

nel that is accessible to them with the least amount of

effort, such as gestures and drawing, rather than spoken

language. A constrained approach for aphasia is incor-

porated in the therapeutic setting by forcing the patient

to communicate only through verbal channels while lim-

iting the use of all other communication channels. The

implementation of CILT in patients with aphasia con-

sisted of intensive practice through a series of language

games requiring verbal production of phrases and sen-tences of increasing length that were shaped into succes-

sively better approximations. Resultscomparing language

improvements after 2 weeks of CILT to approximately

4 weeks of traditional therapy indicated significant im-

provements in the CI group on several standard clinical

tests, self-ratings, and blinded-observer ratings of the

patientscommunicative effectiveness in everyday life.

Two principles of CILT need to be considered when

interpreting the findings. The first principle, forced use

of verbal language, requires that all responses provided

during language treatment activities be constrained or

restricted to the spoken modality. Nonverbal communi-

cation attempts such as gesturing, drawing, or writing

are not allowed and are not considered as communica-

tion intents because participants are on opposite sides of

a barrier. The second principle, massed practice, involves

a high-intensity treatment schedule consisting of 34 hr

of treatment per day for 2 weeks. Participants in the

Pulvermuller et al. (2001) study were randomized to aCILT group and a comparison group that received con-

ventional speech treatment provided on a distributed

schedule over 35 weeks. That is, the groups differed in

two dimensions of treatment: the type of treatment ad-

ministered and the intensity of the treatment provided.

Thus, it is difficult to determine whether the positive

treatment results reported for the CILT group as com-

pared to the conventional treatment group emanate from

the constrained forced language use, the intensity of the

treatmentschedule, or a combination of these two factors.

Intensity of treatment hasbeen a topic of interest for

some time in aphasia treatment studies (Poeck, Huber,& Willmes, 1989). Findings from Robeys (1998) meta-

analysis of the aphasia literature reported large effect

sizes (ESs) associated with treatment provided for 2 or

more hr per week. In a review focused on intensity and

outcomes, Bhogal, Teasell, and Speechley (2003) reported

better treatment outcomes in studies that provided in-

tensive treatment schedules. On average, the more in-

tensive treatment schedules equaled 8.8 hr per week for

11 weeks, compared with the less intensive schedules of

2 hr per week for 23 weeks of treatment. Although both

reviews examined the intensity literature, the schedule

of treatment provided in the cited studies is far less thanthe intensity of services given in CILT.

This review examines the current state of the evi-

dence employing the dual principles of CILT for individ-

uals with stroke-induced aphasia.In additionto analyzing

and synthesizing the scientific research in this area, the

authors piloted the use of a newly created levels-of-

evidence scheme developed by the American Speech-

Language-Hearing Association (ASHA) National Center

for Evidence-Based Practice in Communication Disor-

ders (N-CEP), along with its advisory committee. This

scheme classifies treatment studies according to several

quality indicators and the phase of research (Robey,2004). We piloted this system to determine its applica-

bility to treatment studies in the area of communication

sciences and disorders and provided feedback to N-CEP

and its advisory committee prior to the widespread

adoption of this system.

Clinical QuestionsTen clinical questions were identified by the authors

for review (see Table 1). In constructing these questions,

Cherney et al.:EBSR: Effects of Intensity of Treatment and CILT 1283


3/19

the nature of outcome measurements and stage of re-covery from aphasia were considered. In keeping with

current ASHA policy documents, such as the Scope of

Practice in Speech-Language Pathology (ASHA, 2001),

the World Health Organizations (2001) International

Classification of Functioning, Disability and Health:ICF

was selected to categorize the various outcome measures

representing language impairment (e.g., standard apha-

sia tests of phonology, syntax, and semantics) or commu-

nication activity/participation (e.g., functional real-life

use of language in connected speech measures or com-

munication ratings scales). Because the stage of recovery

from stroke-induced aphasiaacute or chronicinfluences

recovery patterns (Robey, 1998) and studies typically

include participants in only one of these stages, the clin-

ical questions also included participants with chronic

and acute aphasia (distinguished by mean time post

onset [TPO] 3 months). Therefore, eight clinical ques-

tions reflect combinations of the following parameters:

(a) CILT principlesresponse constraint and treatment

intensity; (b) aphasia chronicityacute and chronic; and

(c) outcome measures identified from theICFlanguage

impairment and communication activity/participation.

Two additional questions were constructed to address

maintenance of treatment behavior in chronic aphasia

for a total of 10 clinical questions (see Table 1).

MethodA systematic search of the aphasia literature was

conducted to identify studies that directly investigated

CILT as the specific intervention for aphasia or directly

compared conditions of higher and lower intensity treat-

ment for aphasia. Fifteen electronic databases were

searched: PubMed, CINAHL, PsycINFO, PsycArticles,

CSA Linguistics and Language Behaviour Abstracts,

Combined Health Information Database, Health Source:Nursing, Science Citation Index, ScienceDirect, NeLH,

REHABDATA, Social Science Citation Index, SUMSearch,

TRIP Database, and Cochrane Database of Systematic

Reviews. Additional searches were also performed on all

ASHA journals, the University of Pittsburgh Clinical

Aphasiology Conference Proceedings, National Institutes

of Health (NIH) abstracts, and Google Scholar. In addi-

tion, references from all relevant articles were examined

to identify other applicable studies. A total of 25 ex-

panded search terms included those related to stroke-

induced aphasia, amount and intensity of treatment, and

CILT. Studies were initially considered for the review if

they were published in a peer-reviewed journal from 1990

to 20061, were written in English, and contained original

data addressing 1 or more of the 10 clinical questions. For

studiesaddressing a clinical question related to intensity,

the keyword intensity or amount of treatment had to be

included in the abstract or the title of the article. In ad-

dition, studies were limited to those that included adults

18 years of age or older with stroke-induced aphasia.

Studies that included individuals with underlying cog-

nitive deficits or any other primary medical diagnoses

were excluded. Studies that used pharmacological inter-

vention for aphasia as the comparison treatment were

also excluded.

The initial search schematicized in Figure 1 yielded

441 citations. Two authors (TF and TS), blind to one an-

others results, reviewed each abstract and identified

36 abstracts as meeting the initial inclusioncriteriawith

91% agreement. Of those preliminarily accepted, 26 were

Table 1.Clinical questions.

Question No. Clinical QuestionIntensity

1. For stroke-induced chronic aphasia, what is the influence of treatment intensity on measures of language impairment?2. For stroke-induced chronic aphasia, what is the influence of treatment intensity on measures of communication activity/participation?3. For stroke-induced acute aphasia, what is the influence of treatment intensity on measures of language impairment?4. For stroke-induced acute aphasia, what is the influence of treatment intensity on measures of communication activity/participation?

5. For stroke-induced chronic aphasia, what treatment outcomes are maintained following intensive language treatment?

Clinical QuestionCILT

6. For stroke-induced chronic aphasia, what is the influence of constraint-induced language therapy on measures of language impairment?7. For stroke-induced chronic aphasia, what is the influence of constraint-induced language therapy on measures of communication

activity/participation?8. For stroke-induced acute aphasia, what is the influence of constraint-induced language therapy on measures of language impairment?9. For stroke-induced acute aphasia, what is the influence of constraint-induced language therapy on measures of communication

activity/participation?10. For stroke-induced chronic aphasia, what treatment outcomes are maintained following constraint-induced language therapy?

1The original purpose of the systematic review was to examine the effects

of CILT. It became apparent that it would be impossible to adequately

complete this review independent of addressing treatment intensity, which

is a key principle of CILT. The search date was determined based on the

emergence of CI literature in the early 1990 s.

1284 Journal of Speech, Language, and Hearing Research Vol. 51 12821299 October 2008


4/19

rejected upon review of the full text by the author panel,

as they did not report original data or include direct evi-

dence of a contrast between conditions (e.g., a more in-

tensiveconditionvs. a less intensivecondition) pertaining

to one or more of the clinical questions. Ten studies met

the final inclusion.

Each of these studies was independently reviewed

and evaluated for methodological quality by two of threeauthors (LC, JP, AR). One study written by an author

(AR) was reviewed by two other panel authors (LC, JP).

The authors, blind to one anothers results, appraised

each study on the basis of quality indicators described in

Table 2. For each indicator, quality markers are ordered

from highest to lowest level of quality. A study received

1 point for each quality indicator if the highest level of

quality was incorporated. All nine indicators were rel-

evant to studies incorporating controlled trials, leading

to a maximum quality score of 9. For other study designs,

where intent-to-treat analysis was not relevant, the

maximum quality score was 8. Credit for study design

varied by stage of research (see Table 3). For example,

efficacy studies using controlled trial designs received

1 point. Discovery studies received 1 point for research

design if reporting retrospective case controls or single-

participant studies. Reliability of scores was assessed,

and any discrepancies in scoring were sent back to the

full author panel for resolution. All disagreements were

resolved via consensus.

In addition to assessing methodological quality, the

phase of clinical research was determined using the

decision tree depicted in Figure 2. The four stages of

researchdiscovery, efficacy, effectiveness, and cost

benefit/public policy researchare defined in Table 3.

A final synthesis of the body of scientific literature was

compiled into an evidence table on the basis of the study

quality marker score and corresponding stage of research.

ESs were calculated for outcome measures whenever

possible. For group studies, Cohens d (Cohen, 1988) was

calculated (corrected for bias following Hedges & Olkin,1985). ESs were calculated from group means and stan-

dard deviations or were estimated from results of anal-

yses of variance (ANOVAs) or t tests. We used Cohens

benchmarks for small, medium, and large ESs as .2, .5,

and .8, respectively. Whether these benchmarks are ap-

plicable to aphasia treatment studies has yet to be de-

termined. In the one single-participant experiment

(Raymer, Kohen, & Saffell, 2006), the authors calculated

the weighted ESs using the methods described by Beeson

and Robey (2006). Although Busk and Serlin (1992)

reported that large ESs in single-participant studies sur-

pass 2.5, Beeson and Robey noted benchmarks for small,

medium, and large ESs in single-participant designs as

2.6, 3.9, and 5.8.

ResultsOf the 10 studies that met inclusion criteria for the

systematic review, 5 studies investigated treatment in-

tensity (Basso & Caporali, 2001; Denes, Perazzolo, Piani,

& Piccione, 1996; Hinckley & Carr, 2005; Hinckley &

Craig, 1998; Raymer et al., 2006), 4 studies evaluated

Figure 1. Process for identification of included studies.



5/19

CILT (Maher et al, 2006; Meinzer et al, 2004; Meinzer,

Djundja,Barthel,Elbert,& Rockstroth, 2005; Pulvermuller,

Hauk, Zohsel, Neininger, & Mohr, 2005), and 1 study ex-

amined both (Pulvermuller et al., 2001). These studies

allowed us to address 7 of the 10 clinical questions (see

Table 1): Questions 1, 2, 5, 6, 7, and 10, which are related

to language impairment and communication activity/

participation in individuals with chronic aphasia, and

Question 3, which is related to the effects of treatment

intensity on measures of language impairment for in-

dividuals with acute aphasia. No study investigated

CILT or intensive treatment effects for measures of

Table 2.Quality indicators in the ASHA levels-of-evidence scheme.

Indicator Description Quality marker

Study design The type of design used in the study. Controlled trial(Efficacy research)*Retrospective case control (Effectiveness or

costbenefit research)*Single participant study (Discovery research)*

Case seriesCase study

Blinding The practice of keeping investigators or participants ignorant tothe group to which participants are assigned. For the purposesof the critical appraisal,blindingrefers to assessors only.

Assessors blinded*

Assessors not blinded or not stated

Sampling The method(s) used to choose and assign participants to theexperimental conditions in the study.

Random sample adequately described*Random sample inadequately describedConvenience sample adequately describedConvenience sample inadequately described or

hand-picked sample or not stated

Group/participant

comparability

How similar the participants/groups were at the start of the

study or how adequately they were described.

Groups/participants comparable at baseline

on important factors(between-subject design)or participant(s) adequately described(within-subject design)*

Groups/participants not comparable at baselineor comparability not reported or participant(s)not adequately described

Treatment fidelity The procedure used to ensure that the treatmentwas delivered as intended.

Evidence of treatment fidelity*No evidence of treatment fidelity

Outcomes The measure(s) used in the study to quantify improvement. At least one primary outcome measure isvalid and reliable*

Validity unknown, but appears reasonable;measure is reliable

Invalid and/or unreliable

Significance The likelihood that the study findings occurred by chance. pvalue reported or calculable*pvalue neither reported nor calculable

Precision The size or magnitude of any difference found between thetreatment under investigation and the control condition.

Effect size and confidence intervalreported or calculable*

Effect size or confidence interval, but notboth, reported or calculable

Neither effect size nor confidenceinterval reported or calculable

Intent-to-treat(controlled trials only)

Participants are analyzed according to the group to which they wereinitially assigned, regardless of whether or not they dropped out,

fully complied with the treatment, or crossed over and receivedthe other treatment.If number of participants at pre-treatment =number at post-treatment, study received credit.

Analyzed by intent-to-treat*Not analyzed by intent-to-treat*

*Highest level of quality needed to receive 1 point.



6/19

communication activity/participation in acute aphasia

(covered in Questions 4, 8, and 9).

Participants

Table 4 provides a detailed description of the 141 par-

ticipants in the 10 studies (e.g., age, education level,

gender, handedness, TPO, aphasia type, and severity).

The total sample size (N) of participants reported in the

studies does not account for the possible overlap of par-

ticipants across four studies: Pulvermuller et al. (2001

and 2005) and Meinzer et al. (2004 and 2005).

For the intensity studies, type of aphasia was pro-

vided in five studies; 81% (55 of 68) of the participants

were nonfluent. Severity of aphasia was provided in four

studies; 40% (23 of 57) of participants tended to have

more severe aphasia, with 30% (19 of 63) of participantsbeing described as having global aphasia. The mean TPO

was considered acute in one study (3.1 months in Denes

et al., 1996);the other studies included participantswith

chronic aphasia, ranging from 11.2 to 67.6 monthspostonset.

Similarly for the CILT studies, 60% of participants

(42 of 70) had nonfluent forms of aphasia, typically de-scribed as Brocas aphasia. Most had moderate aphasia

(48%, 30 of 62), whereas 19 participants (31%) had mild

aphasia and 12 participants (19%) had severe aphasia.

Mean TPO ranged from 36.8 months to 90 months, all in

the chronic range.

Four of the 10 studies were conducted in Germany,

4 in the United States (U.S.), and 2 in Italy. Two German

studies (Pulvermuller et al., 2001, 2005) included mono-

lingual native speakers of German. The other two Ger-

man studies (Meinzer et al., 2004, 2005) did not mention

linguality of the participants. Two U.S. studies (Hinckley

& Carr, 2005; Hinckley & Craig, 1998) noted that all par-ticipants were native speakers of English, whereas two

Figure 2. Stage of research.

Table 3.Continuum of research stages.

Stage Description

Discovery Treatment approaches are developed and assessed in the context of whetherthey show promise of being efficacious.

Efficacy Promising interventions are tested in a rigorous way under ideal, highlycontrolled conditions to determine the outcome that results.

Effectiveness The intervention is tested in a real-worldclinical setting. This phaseis often conducted if the intervention demonstrates positive outcomes in ahighly controlled setting of a clinical trial.

Costbenefit/public policy A study is conducted of the political and economic environment in which theintervention is best delivered. This phase is often conducted once it hasbeen shown that an intervention is both efficacious and effective.



7/19

Table 4.Patient characteristics.

Study N Age Education Gender Handedness TPO Etiology

Basso & Caporali,2001 (Intensity)

6 3548 yrs 817 yrs 4 M R 222 months 2 hemorrhagic M= 41 yrs M= 12.5 yrs 2 F M= 11.2 months 4 ischemic

2 n

Denes et al.,

1996 (Intensity)

17 60.2 yrs 7.2 yrs 8 M R 2.44.5 months 4 hemorrhagic

9 F M= 3.1 months 13 ischemicHinckley & Craig,

1998, Study 3(Intensity)

10 2578 yrs 12+ yrs 6 M 9 R 7 47 months Thromboembolic M= 48 yrs 4 F 1 L M= 20 months

Hinckley & Carr,2005 (Intensity)

13 1972 yrs NR NR R 699 months L CVA M= 50 yrs M= 27 months intensive 1

M= 40 months nonintensive

Maher et al., 2006 (CILT) 9 4173 yrs 1216+ yrs 6 M 8 R 1472 months L CVA M= 58 yrs 3 F 1 R+ M= 36.8 months

Meinzer et al., 2004 (CILT) 28 3580 yrs NR 14 M R 12156 months 20 ischemic M

= 54.6 yrs 14 F M

= 43.8 months 8 hemorrhagic

Meinzer et al., 2005 (CILT) 27 1880 yrs NR 16 M NR 13116 months 11 hemorrhagic M= 51.5 yrs 11 F M= 43.1 months 16 ischemic

Pulvermuller et al., 2001(CILT and Intensity)

17 4272 yrs 913 years 12 M 14 R 2223 months L CVA M= 54.9 yrs M= 11 yrs 5 F 3 R+ M= 67.6 months

Pulvermuller et al.,2005 (CILT)

9 3972 yrs 1013 yrs 6 M 7 R 16223 months L CVA M= 54.4 yrs M= 11.3 yrs 3 F 2 R+ M= 90 months

Raymer et al.,2006 (Intensity)

5 5182 yrs 814 yrs 2 M 5 R 442 months L CVA M= 70.8 yrs M= 11.4 yrs 5 F M= 18.4 months

1

Note. TPO = time postonset; yrs = years; NR = not reported; R+ = ambidextrous; L CVA = left cerebrovascular accident; NS = not severe; BDAE =Kaplan, 1983).

1288

JournalofSpeech,

Language,andHearingResearch

Vol.51

12821299

October2008


8/19

other U.S. studies (Maher et al., 2006; Raymer et al.,

2006) did notaddress linguality. OneItalian study (Denes

et al., 1996) included only native speakers of Italian. The

second Italian study (Basso & Caporali, 2001) included

5 participants who were native speakers of Italian and 1

who was a native of Sweden and completely bilingual.

The educational level of the participants was reported

in only 6 of the 10 studies. The mean years of educa-tion varied from 10.9 years (Pulvermuller et al., 2001) to

15 years (Maher et al., 2006). One study (Hinckley &

Craig, 1998) reported that all participants completed

high school or above, and the Basso and Caporali (2001)

study reported educational attainment on only 4 of 6 par-

ticipants. Only one study (Hinckley & Carr, 2005) reported

mean data on socioeconomic status. Those participants

had a mean score of 2.3 on the Hollingshead Four Factor

Index of Social Status (Hollingshead, 1975).

Study Characteristics and QualityTable 5 summarizes information regarding the in-

tervention, including schedule, amount and duration of

treatment, andoutcome measures. Most studies provided

2430 hr of treatment; several studies reported more

than 100 hr of treatment (e.g., Hinckley & Craig, 1998).

Treatment schedules varied across studies, as did the

nature of treatment provided.

Table 6 displays quality marker ratings obtained for

the studies. All 10 studies described participants suf-

ficiently and reported data in a manner in which statis-

tical significance was available. Studies were lacking in

several areas, however, including useof a clearly describedrandomized assignment scheme for participants in group

designs, provided in only one study; blinding of assessors

to treatment conditions, indicated in only two studies; and

providing evidence of treatment fidelity, also noted in

only two studies.

Four studies were judged as discovery phase re-

search and five studies as efficacy research. Only one

study fell into the effectiveness stage of research, and

none addressed costbenefit or public policy.

Intensity ResultsTable 7 displays stage of research, quality scores,

and ESs for the six studies examining treatment inten-

sity. These studies addressed Questions 1, 2, 3, and 5

(see Table 1). No data were available to answer Ques-

tion 4. Five of these studies contained sufficient data

for calculation of treatment ESs. The effect of intensity

in Denes et al. (1996), Pulvermuller et al. (2001), and

Hinckley andCarr (2005) wasderivedfrombetween-group

comparisons for groups receiving intensive and non-

intensive treatment. The effect of intensity in Study 3 of

Hinckley andCraig (1998) wasderived from within-group

comparisons of the pre- and post difference scores from

each intensive 6-week training session compared with the

nonintensive 6-week training session. In Raymer et al.

(2006), the effects came from within-subject comparisons

across the individual participants.

Clinical Question 1: For stroke-induced chronic apha-

sia, what is the influence of treatment intensity on mea-

sures of language impairment? Four group studies usedimpairment outcome measures for which eight ESs were

calculable, including seven large ESs, all in favor of more

intensive treatment. In the single-participant design of

Raymer et al. (2006), ESs were larger in the more inten-

sive condition for picture-naming acquisition and larger

in the less intensive condition for word/picture verifica-

tion. ESs could not be calculated for Basso and Caporali

(2001), who described case studies of three pairs of indi-

viduals. Individuals receiving more intensive treatment

showedgreatergains on language impairment tasks than

didthecomparison individualswhoreceiveda lessintensive

schedule. Thus, the language impairment outcome mea-sures favored more intensive treatment for all language

measures except one in participants with chronic aphasia.


sia, what is the influence of treatment intensity on mea-

sures of communication activity/participation? Three

group studies used communication measures for which

nine ESs were calculable, including content unit (CU)

analysis, oral and written responses on a catalogue order-

ing task administered in quiet and concurrent noise con-

ditions, and the Communication Activities of Daily Living

(CADL2; Holland,Frattali, & Fromm, 1999). ESsranged

from 1.15 to 3.78, with five favoring more intensive treat-ment (four large effects) and four favoring less intensive

treatment (two large effects).

Basso and Caporali (2001) also contributed data to

this clinical question, as they described greater changes

in participants conversational abilities in all persons re-

ceiving more intensive treatment as compared with the

counterpart receiving less intensive treatment. Overall,

findings for outcome measures of communication activity/

participation were mixed, with some favoring less in-

tensive treatment and others favoring more intensive

treatment.

Clinical Question 3: For stroke-induced acute aphasia,

what is the influence of treatment intensity on measures of

language impairment? In one study of 17 individuals,

(Denes et al., 1996), the ESs for the Aachen Aphasia Test

(AAT; Huber, Poeck, & Williams, 1984) ranged from 0.39

(repetition tasks) to 1.20 (written language tasks), all fa-

voring more intensive treatment.


sia, what treatment outcomes are maintained following

intensive language treatment? In the single-participant

design of Raymer et al. (2006), ESs for picture-naming



9/19

Table 5. Intervention variables.

Study Treatment program Treatment schedule Total amount Durat


All participantsindividual treatment; conventionalaphasia treatment; varied techniques.

More intensivetreatment

NR All partic

Goal areas= auditory comprehension, repetition,naming, and conversation.

3 participants 5 hr/wk;Home program

1440 m

Treatment programmore intensive = clinic + homeprogram; less intensive = clinic.

23 hr/dayLess intensive

treatment3 participants;

5 hr/wk

Denes et al., 1996(Intensity)

All participantsindividual treatment; ecological,based on stimulation approach to restore efficient useof language mainly in conversation.

All participants Intensive treatmentgroup

All partic

Goal areas= auditory comprehension and verbalproduction.

45- to 60-min sessionsM= 130 sessions,

SD= 36,range = 94160

M= 6 mrange = 5

Technique= picture identification and conversation context.

Intensive treatmentgroup

Regular treatmentgroup

67 sessions/wk

M= 60 sessions,

SD= 14,range = 5670

Regular treatmentgroup

About 3 sessions/wk

Hinckley & Craig,1998, Study 3(Intensity)

All participantsindividual, group and computer treatment;functionalist/pragmatic approach. Standard functionaltreatments (i.e., PACE and cueing hierarchy).

Intensive treatmentphase

All participants All partic

23 hr/wk294306 hrs 18 wk

Nonintensivetreatment phase

6 wks intensivephase

35 hr/wk6 wks nonintensive

phase6 wks intensive

phase


All participantscontext-based treatment that is basedon whole-task training and ecological validity.

Intensive treatmentgroup

Total number ofsessions per

participant-NR

NR

Tasks= problem-solving catalogue ordering taskto develop compensatory strategies.

20 hrs individualtreatment/wk; 5 hrgroup treatment/wk

All participantsTechniques= role play, strategy development,

and context-specific cues. Nonintensivetreatment group

Minutes to reachcriterion on

catalogue ordering taskTreatment groupintensive treatment = individual + group;nonintensive treatment = individual. 4 hr individual

treatment/wkM= 233,

range = 29597(110 sessions)

(Continued on the following page)

1290

JournalofSpeech,


Vol.51

12821299

October2008


10/19

Table 5Continued. Intervention variables.

Study Treatment program Treatment schedule Total amount Durati

Maher et al.,2006 (CILT)

All participantstask = primarily dual card task. All participants All participants All particTechnique= shaping and cueing. 3-hr sessions 24 hr 2 wkTreatment groupCILT = verbal response required. 4 sessions/wk PACE = all communication modalities permitted.

Meinzer et al.,2004 (CILT)

Treatment groupCIAT Verbal response required. Dualcard task (object drawings) 23 participants per group.

All participants All participants All partic

Technique= shaping and cueing. Model-based aphasiatreatment; deficit-specific approach.

3 hr/day for 10 days 30 hr 2 wk

NR = individual or group treatment.


Treatment groupCIAT = verbal response required; dual

card task (object drawings); 23 participants per group.

All participants All participants All particTechnique= shaping.3 hr/day for 10 days 30 hr 2 wkCIAT plus = CIAT as above, plus dual card task (object

drawings, written words, and photographs); dailyhome program; daily communication practice withfamily members.

Pulvermuller et al.,2001 (CILT andIntensity)

Treatment group CIAT group CIAT group CIAT grCIAT = verbal response required; dual card task

(object drawings); 23 participants per group.3 hr/day for 10 days M= 31.5 hr,

range = 23332 wee

Technique= Shaping and reinforcement.Conventional aphasia treatmentsyndrome-specific standard approach; naming, repetition,

sentence completion, and conversation tasks.

Conventionaltreatment group Conventional

treatment group

Conventtreatment

35 wkSession length NRM = 33.9 hr,

range = 2054

35 wks

(Continued on the following page)

Cherney

etal.:EBSR:EffectsofIntensityofTreatmentandCILT

1291


11/19

Table 5Continued. Intervention variables.

Study Treatment program Treatment schedule Total amount Durati


All participantsCIAT; verbal response required; dual cardtask (object drawings); 3 participants per group.

All participants All participants All partici

Technique= shaping and reinforcement.3 hr/day for 10 days M= 31.3 hr,SD= 3.5,

range = 23332 wk


All participantsMoss-talk multimode matching exercises;spoken and written word/picture matching.

All participants All participants NRAlternating treatment

schedules35 baseline sessions

34 sessions/wk12 training sessions

12 sessions/wk1-month break

12 training sessions4 participants = 24 hr1 participant = 22 hr

Note. NR = not reported; AAT = Aachen Aphasia Test (Huber, Poeck, & Weniger, 1984); ANT = Action Naming Test (Nicholas, Obler, Albert, & GGoodglass, & Weintraub, 2001); CADL = Communication Activities of Daily Living (Holland, Frattali, & Fromm, 1999); CAL = Communication Activity Effectiveness Index (Lomaset al.,1989);CU = content unit; PACE = Promoting Aphasics Communicative Effectiveness (Davis & Wilcox, 1985); PALPA

Aphasia (Kay, Lesser, & Coltheart, 1992); TT = Token Test (De Renzi & Vignolo, 1962); WAB = Western Aphasia Battery (Kertesz, 1982).

1292

JournalofSpeech,


Vol.51

12821299

October2008


12/19

maintenance were 7.45 in the more intensive condi-

tion and 4.85 in the less intensive condition. ESs for a

word/picture verification task were 1.75 in the more

intensive condition and 2.14 in the less intensive con-

dition. Thus, maintenance effects of treatment inten-

sity were mixed in this study.

Stage of research and quality. Table 7 also shows the

number of quality markers for each study and the stage

of research.Of the two studies in the discovery phase of

research, one received a quality marker score of 5 out of

8 (Raymer et al., 2006) and the other received a qualitymarker score of 3 out of 8 (Basso & Caporali, 2001). Three

studies were efficacy studies (Denes et al., 1996; Hinckley

& Carr, 2005; Pulvermuller et al., 2001), each of which

attained a quality marker score of 6 or 7 out of 9. One

study (Hinckley & Craig, 1998) fell into the effectiveness

stage of research, achieving a quality score of 4 out of 8.

CILT Results

CILT was examined in five studies as shown in

Table 8. These studies addressed Questions 6, 7, and 10.

No studies of CILT in acute aphasia were available, so

Questions 8 and 9 could not be addressed. Cohens dval-

ues could be calculated for all five CILT studies. The ESs

for Meinzer et al. (2004, 2005), and Pulvermuller et al.

(2005) represent within-subject effects, whereas those in

Maher et al. (2006) and Pulvermuller et al. (2001) come

from between-group comparisons of CILT witha contrast-

ing treatment.


sia, what is the influence of constraint-induced language

therapy on measures of language impairment?Across thefive group studies, 16 ESs were calculable, including 9

large ESs in favor of CILT. In individuals with chronic

aphasia, CILT hadpositive effects for overall aphasia bat-

tery scores (Maher et al., 2006; Meinzer et al., 2004) and

subtests of auditory comprehension, word retrieval, repe-

tition, and lexical decision (Maher et al., 2006; Meinzer

et al., 2004; Pulvermuller et al., 2005).

Meinzer et al. (2005) examined a modification of

CILT (described as CIAT) in which additional home ac-

tivities were included. There was no difference between

CILT and CIAT plus on outcome scores immediately

Table 6.Study quality marker variables.

Study DesignAssessorblinding

Randomsamplingdescribed

Participantscomparable/

describedTreatment

fidelity reportedValid outcome

measure SignificanceIntent-to-treat Precision


Case study No No Yes No Yes Yes N/A No

Denes et al., 1996(Intensity)

Controlledtrial

Yes No Yes No Yes Yes Yes Yes

Hinckley & Craig,1998, Study 3(Intensity)

Case series No No Yes No Yes Yes N/A Yes


Controlledtrial

No No Yes Yes Yes Yes Yes Yes

Maher et al.,2006 (CILT)

Controlledtrial

No No Yes Yes Yes Yes No Yes




Controlledtrial

No No Yes No Yes Yes Yes No

Pulvermuller et al.,2001 (CILTand Intensity)

Controlledtrial

Yes Yes Yes No Yes Yes No No




Single subject No No Yes No Yes Yes N/A Yes

Note. N/A = not applicable.



13/19

following training. Both groups reported significant im-

provements. For language impairment measures, CILT

consistently led to positive outcomes.

Clinical Question 7: For stroke-induced chronic

aphasia, what is the influence of constraint-induced lan-

guage therapy on measures of communication activity/

participation?Three of the 5 CILT studies included mea-

sures of communication activity/participation; ESs could

be calculated for 11 outcome measures incorporated in the

studies (e.g., Communicative Activity Log, storyretelling,

Communicative Effectiveness Index; Lomas et al., 1989).

ESs ranged from.82 to 3.77, with eight favoring CILT (six

large effects) and three favoring a comparison treatment

(one large effect). Thus, CILT had positive outcomes for

several measures of communication activity/participation,

although some favored a comparison condition.

ClinicalQuestion 10: For stroke-induced chronic apha-

sia, what treatment outcomes are maintained following

Table 7. Intensity studies, effect sizes, and methodologic quality.

Study Outcome measure(s) ICF Intensity effect sizeResearch

stageQuality

scoreClinical

question

Basso & Caporali, 2001 AAT TT I Not calculable Discovery 3 of 8 1, 2Ravens matricesa IPicture description I

Denes et al., 1996 AAT: TT I 0.60 Efficacy 7 of 9 3Repetition I 0.39Written Language I 1.20Naming I 0.73Comprehension I 0.91Profile Level I 0.83

Hinckley & Craig, 1998, Study 3 Intensive Treatment I vs. Nonintensive Effectiveness 4 of 8 1, 2BNT I 1.12Content Unit Analysis A/P 0.53

Intensive Treatment II vs. NonintensiveBNT I 0.95Content Unit Analysis A/P 0.74

Hinckley & Carr, 2005 Catalogue ordering Efficacy 7 of 9 1,2Oral (quiet) A/P 0.81Oral (concurrent) A/P 0.05Written (quiet) A/P 0.54Written (concurrent) A/P 0.18

CADL-2 A/P 1.15PALPA Oral Naming I 0.16PALPA Written Naming I 1.48

Pulvermuller et al., 2001 AAT: Overall Test Scores I 2.18 Efficacy 6 of 9 1, 2TT I 0.92Naming I 1.12Language Comprehension I 1.12

Repetition I Not calculableCommunicative Activi ty Log: Patients A/P 3.78SLPs A/P 2.64

Raymer et al., 2006 WAB Aphasia Quotient I Not calculable Discovery 5 of 8 1, 5BNT I Not calculablePicture Naming Acquisition I 4.35 (lw), 11.37 (hw)Picture Naming Maintenance I 4.85 (lw), 7.45 (hw)Word/Picture Verification Acquisition I 2.72 (lw), 2.14 (hw)Word/Picture Verification Maintenance I 2.14 (lw), 1.75 (hw)

Note. lw = low weighted intensity; hw = high weighted intensity; ICF = International Classification System; I = impairment; A/P = activity/participationSLP = speech-language pathologist.aRavens Coloured Progressive Matrices (Raven, Court, & Raven, 1986)



14/19

constraint-induced language therapy? Two studies ad-

dressed Question 10. Meinzer et al. (2005) reported that

effects of CILT on measures of language impairment

and communication activity/participation were main-

tained at 6 months compared with baseline performance.Family members of the group receiving CIATplus with

the modified home program reported further gains in

communication effectiveness over the 6-month period.

Maher et al. (2006)reported follow-up testing at 1 month

post-CILT completion. Three of 4 CILT participants and

1 of 3 participants in Promoting Aphasics Communica-

tive Effectiveness (PACE) demonstrated continued in-

creases on aphasia tests over the 1-month period.

Stage of research and quality.Table 8 indicates that

two studies that fell into the discovery phase of re-

search received quality scores of 4 out of 8. Three studies

represented efficacy research, two of which received a

quality marker score of 6 out of9 and one of which received

a score of 5 out of 9.

DiscussionThe purpose of this EBSR was to assess the in-

fluence of intensity of language treatment and CILT on

language and communication outcomes of individuals

with stroke-induced aphasia. A systematic search of the

literature from 1990 to 2006 yielded only 10 studies that

met predetermined inclusion criteria, with 5 studies ad-

dressing treatment intensity, 4 studies addressing CILT,

and 1 study addressing both. Although few studies were

expected to be found for CILTa technique that was

Table 8.CILT studies, effect sizes, and methodologic quality.

Study Outcome measure(s) ICF CILT effect size Research stage Quality score Clinical question

Maher et al., 2006 Aphasia tests Efficacy 6 of 9 6, 7, 10WAB Aphasia Quotient I 1.01BNT I 0.16Action Naming Test I 0.14

Linguistic measures in story retellingNumber of words A/P 0.72Number of utterances A/P 0.82Number of sentences A/P 0.19Mean length of utterance A/P 0.33

Clinician ratings A/P Not calculable

Meinzer et al., 2004 AAT: Profile I 0.34 Discovery 4 of 8 6Token Test I 0.81

Meinzer et al., 2005 AAT: Profile I 1.63 Efficacy 5 of 9 6, 7, 10Subtests I Not calculable

CETI: Overall relatives A/P 1.86Communication Activity Log

Quantity: Patients A/P 1.99Relatives A/P 2.35

Comprehension: Patients A/P .47 Relatives A/P 1.13

Pulvermuller et al., 2001 AAT: Overall Test Scores I 2.18 Efficacy 6 of 9 6, 7 TT I 0.92Naming I 1.12Language Comprehension I 1.12Repetition I Not calculable

Communicative Activity Log: Patients A/P 3.77SLPs A/P 2.64

Pulvermuller et al., 2005 AAT: TT I 0.25 Discovery 4 of 8 6

Repetition I 0.11Naming I 0.25Comprehension I 0.46

Lexical decision reaction timesResponse time I 2.39Pseudowords x time I 3.32Words I Not calculable



15/19

introduced only in 2001the paucity of studies directly

addressing treatmentintensity was surprising in view of

the overall large number of studies examining language

treatment for stroke-induced aphasia. Given the small

number of studies, the conclusions of the present sys-

tematic review must be considered preliminary. Further-

more, interpretation of ESs and their applicability to the

aphasia literature is not certain at this time. Neverthe-less, certain trends in the literature from 1990 to 2006

may usefully inform both clinical practice and future re-

search in this area.

Increased treatment intensity was associated with

positive changes in outcome measures of language im-

pairment in 68 persons with chronic and acute aphasia.

All ESs calculated for group comparisons on language

impairment measures favored more intensive treatment

over less intensive treatment, including seven large ef-

fect sizes. In the single-participant study (Raymer et al.,

2006), ESsfor one measure favored more intensive treat-

ment and one favored less intensive. The data for Clin-ical Question 2 addressing change in communication

activity/participation were mixed, with some favoring

more intensive treatment and some favoring less inten-

sive treatment for persons with chronic aphasia. These

observations suggest that there can be complex interac-

tions among intensity of treatment schedule, type of

treatment, and type of outcome measure.

Maintenance of treatment intensity effects were

reported in one study of persons with chronic aphasia

(Raymer et al., 2006). Findings also were equivocal, fa-

voring more intensive treatment for one outcome mea-

sure and less intensive treatment for the other. However,there was only one data point for each maintenance ob-

servation. Beeson and Robey (2006) suggest a minimum

of two data points for calculation of an ES. Therefore, this

result should be taken with caution.

Overall, five studies involving 90 participants

reported that CILT resulted in positive changes on mea-

sures of language impairment and communication activity/

participation in individuals with chronic aphasia, in-

cluding large ESs for 9 of 16 impairment measures and

6 of 11 activity/participation measures. Meinzer et al.

(2005) reported that effects were maintained for as long

as 6 months following completion of CILT in 27 patients.No data addressed the effect of CILT in patients with

acute aphasia, however. Finally, it is important to note

that Maher et al. (2006) also found significant improve-

ments on language measures for participants in their

control group, who participated in an intensive version

of PACE in which use of compensatory modalities is al-

lowed. This finding implies that intensity is a key com-

ponent of CILT.

Interpretation of the results of this EBSR and its

implications for clinical practice must be considered in

conjunction with the information about characteristics

of the participants. For the intensity studies, the major-

ity of participants had nonfluent forms of aphasia. When

severity of aphasia was provided, the majority of partic-

ipants tended to have more severe aphasia, with many

described as having a global aphasia. Therefore, conclu-

sions regarding intensity of treatment are most applica-

ble to individuals with severe nonfluent aphasia. Futureresearch needs to address, in particular, the impact of

treatment intensity for participants presenting with a

milder aphasia as well as participants who are catego-

rized as fluent. Similarly for the CILT studies, the ma-

jority of participants were nonfluent and moderately

impaired, thereby limiting the generalizability of the re-

sults in individuals with fluent aphasia and individuals

with mild and severe aphasia. Chronicity of aphasia is

another participant characteristic that requires atten-

tion in future studies. No study of CILT included in-

dividuals with acute aphasia, and only one treatment

intensity study addressed the impact of intensity onacute aphasia.

One of the difficulties encountered in this system-

atic review was that of comparing results across studies

when there were differences in the outcome measures

used. Therefore, we attempted to find commonalities

by categorizing the types of outcome measures accord-

ing to the WHO (2001) ICFlevels of body function (lan-

guage reception and production impairment) and activity/

participation. Overall, all of the studies included at least

one outcome measure at the language impairment level

and most of these measures were standardized, valid as-

sessment instruments. Although all of the CILT studiesand four of the six intensity studies included at least

one measure at the communication activity/participation

level, there were fewer of these measures, they were typ-

ically individualized, and information on their validity

and reliability was often lacking. Future studies of CILT

and clinical practice should consider inclusion of more

measures at the communication activity/participation

level as well as studies that address quality of life in

patients with aphasia.

The variety of primary and secondary outcome mea-

sures made comparisons across studies difficult and com-

plicated the determination of the validity and reliabilityas they contribute to the quality of the study. Therefore,

our critical appraisal used a quality marker related to

outcome measuresthat represented only a minimal level

of quality in these areas. All studies achieved this min-

imal level of quality that related to use of a valid and

reliable primary outcome measure.

A number of methodological weaknesses in the 10

studies included in the EBSR were identified during the

critical appraisal of the quality of each study. The short-

comings across the studies related to primarily three



16/19

quality indicators: random assignment of subjects, as-

sessor blinding, and evidence of treatment fidelity. In

most of the studies, regardless of stage of research and

research design, participants were selected as a conve-

nience sample. Randomization is critical for future re-

search, as many evidence-based review organizations

(e.g., The Cochrane Collaboration) include primarily ran-

domized trials in their systematic reviews of health careinterventions. It is also essential that investigators doc-

ument procedures to ensure fidelity of the actual treat-

ment techniques and that some measure of procedural

reliability is provided. Clear documentation of the treat-

ment technique will facilitate the transference of the tech-

nique to the clinical setting.

Examination of the studies in relation to stage of re-

search clearly shows where the strengths of the current

research lie and the direction of future research. In-

cluded studies in the present EBSR were three efficacy

studies evaluating the impact of intensity on stroke-

related chronic aphasia and three efficacy studies eval-uating the impact of CILT on chronic aphasia. Only one

intensity study evaluated effectiveness, and no study

evaluated effectiveness of CILT. No studies in either cat-

egory assessed policy change or cost effectiveness. There-

fore, as evidence for efficacy of more intensive treatment

and CILT continues to grow, future research must ad-

dress issues of effectiveness and cost effectiveness with

studies that are designed according to the criteria in-

cluded in the ASHA levels-of-evidence scheme to ensure

that the studies are of high quality.

Regardless of type of treatment, our general con-

clusions indicate that more treatment is better over a re-stricted time interval. No studies have addressed what

might be the optimum amount and intensity of treat-

ment; however, it is possible that no single answer exists

and that optimum dosage of high-intensity treatment

varies depending on the type of treatment and the char-

acteristics of the participants aphasia, including chro-

nicity. Future studies, beginning at the discovery phase,

are needed to address the many confounds inherent in

resolving the issue of optimum intensity of treatment for

individuals with stroke-induced aphasia.

Although this systematic review has highlighted the

potential efficacy of CILT on the basis of its dual prin-ciples, future studies need to be designed with the aim of

teasing out theimpact of constraint and intensity on out-

come. This task is particularly difficult because high in-

tensity is such an integral part of CILT. However Maher

et al. (2006) have demonstrated that it is possible to ad-

dress this issue methodologically by providing an iden-

tical schedule of CILT and its control treatment. Although

results suggest that efficacy is related to the nature of the

treatment (i.e., constraint) rather than to intensity alone,

given the small number of participants, results are not

yet conclusive. More definitive evidence will be derived

only from (a) conducting randomized studies comparing

CILT with other treatment procedures given at a simi-

lar intensity schedule using participants of similar type

and severity of aphasia and (b) measuring outcomes at

the levels of language impairment and communication

activity/participation. Additionally, the optimum inten-

sity of treatment for CILT has yet to be determined. Fur-ther studies comparing constraints at different levels of

intensity are needed.

Although the early evidence surrounding the efficacy

of CILT for individuals with aphasia shows some promise,

the effects are similar to other intensive treatments that

do not employ the use of constraint. Therefore, these re-

sults should be taken under advisement. Clear and con-

vincing evidence supporting the effectiveness of CILT

over other aphasia treatments has not yet been estab-

lished, and further research comparing aphasia treat-

ments is warranted. Clinicians should interpret the

findings from this EBSR conservatively and always inconjunction with their patients unique characteristics,

circumstances, and preferences when considering the

best course of treatment for and with their clients.

Finally, some observations need to be made following

this pilot implementation of ASHAs levels-of-evidence

scheme. The indicators used to judge the quality of re-

search studies tend to focus on issues that are most per-

tinent to group study designs. Therefore, the usefulness

of the levels-of-evidence scheme in evaluating single-

participant research designs, which are used commonly

in the speech-languagepathology literature, is in need of

further development. Although eight of the nine indica-tors were applicable to single-participant design research,

other quality indicators related to the documentation of

experimental control and threats to external validity (e.g.,

stabilityof baselinemeasures) that areunique to this type

of research were not included. These additional issues of

design quality that arise in single-participant research

will need to be studied.

Another notable aspect of the current systematic re-

view is that all studies addressing the clinical questions,

including discovery studies, are included. Although

some systematic reviews include only group designs or

randomized clinical trials, we elected to include all stud-ies, regardless of design. Ultimately, we need to give

greater weight to well-designed randomized trials. How-

ever, given the relative paucity of those studies in our

current literature base, the inclusion of all possible stud-

ies gives a broader perspective of thestate of knowledge.

It is our hope that this systematic review will incite ad-

ditional rigorous clinical trials addressing the questions

of intensity of aphasia treatment and CILT, as well as

other areas of interest to the fields of speech-language

pathology and audiology.



17/19

Acknowledgments

This EBSR was supported by ASHAs National Center

for Evidence-Based Practice in Communication Disorders

(N-CEP), the Advisory Committee on Evidence-Based Practice

in Communication Disorders, and ASHAs Special Interest

Division 2: Neurophysiology and Neurogenic Speech and

Language Disorders. We thank the following individuals who

contributed to the preparation of this article: Rob Mullen,N-CEP Director; Beverly Wang, N-CEP Information Manager;

and Floyd Roye, N-CEP Project Administrator. All members

of this evidence-based review panel agreed to declare no

competing interests in relation to this article. No author had

any paid consultancy or any other conflict of interest with this

document. The first three authors contributed equally to the

preparation of this article, and the order does not reflect any

differences in contribution.

References

ASHA.(2001).Scope of practice in speech-language pathology

[Scope of Practice]. Available from www.asha.org/policy.

Basso, A. A., & Caporali, A. (2001). Aphasia therapy or theimportance of being earnest. Aphasiology, 15,307332.

Beeson, P., & Robey, R. (2006). Evaluating single-subjecttreatment research: Lessons learned from the aphasialiterature.Neuropsychological Review, 16,161169.

Bhogal,S. K., Teasell,R., & Speechley, M. (2003). Intensityof aphasia therapy, impact on recovery.Stroke, 34,987993.

Busk, P. L., & Serlin, R. (1992).Meta-analysis for single caseresearch. In T. R. Kratochwill & J. R. Levin (Eds.), Single-case research design and analysis: New directions for psy-chology and education. Hillsdale, NJ: Erlbaum.

Cohen, J. (1988). Statistical power analysis for the behavioral

sciences(2nd ed.). Hillsdale, NJ: Erlbaum.

Davis, G. A., & Wilcox, M. (1985).Adult aphasia rehabilita-tion: Applied pragmatics. San Diego, CA: College Hill Press.

Denes, G., Perazzolo, C., Piani, A., & Piccione, F. (1996).Intensive versus regular speech therapy in global aphasia:

A controlled study.Aphasiology, 10, 385394.

De Renzi, E., & Vignolo, L. (1962). The Token Test: Asensitive test to detect receptive disturbances in aphasics.

Brain, 85, 665678.

Goodglass, H., & Kaplan, E. (1983).The Boston DiagnosticAphasia Examination. Philadelphia: Lea & Febiger.

Hakkennes, S., & Keating, J. (2005). Constraint-induced

movement therapy following stroke: A systematic review ofrandomized controlled trials. Australian Journal of Physio-therapy, 51,221231.

Hedges, L. V., & Olkin,I. (1985).Statistical methods for meta-analysis. Orlando, FL: Academic Press.

Hinckley, J. J., & Craig, H. K. (1998). Influence of rate oftreatment on the naming abilities of adults with chronicaphasia. Aphasiology, 12,9891006.

Hinckley, J. J., & Carr, T. (2005). Comparing the outcomes ofintensive and non-intensive context-based aphasia treat-ment.Aphasiology, 19,965974.

Holland, A., Frattali, C., & Fromm, D. (1999). Communica-tion activities of daily living (2nd ed.). Austin, TX: Pro-Ed.

Hollingshead, A. B. (1975).Four Factor Index of SocialStatus. New Haven, CT: Yale University.

Huber, H. P., Poeck, K., & Williams, K.(1984). The AachenAphasia Test. In F. C. Rose (Ed.), Progress in aphasiology(pp. 291303). New York: Raven Press.

Huber, W., Poeck, K., & Weniger, D. (1984). The AachenAphasia Test.In F. C. Rose (Ed.),Advances in neurology, Vol. 42:Progress in aphasiology. New York: Raven Press.

Kaplan, E., Goodglass, H., & Weintraub, S. (2001).TheBoston Naming Test. Philadelphia: Lea & Febiger.

Kay, J., Lesser, R., & Coltheart, M. (1992). Psycholinguisticassessments of language processing in aphasia. Hove, UnitedKingdom: Psychology Press.

Kertesz, A. (1982). Western Aphasia Battery. Orlando, FL:Grune & Stratton.

Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitationafter brain damage.Journal of Speech-Language-Hearing

Research, 51(Suppl.), S225S239.

Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson,A., & Zoghaib, C. (1989). The Communicative Effective-ness Index: Development and psychometric evaluation ofa functional communication measure for adult aphasia.

Journal of Speech Hearing Disorders, 54,113124.

Maher, L., Kendall, D., Swearengin, J., Rodriguez, A.,Leon, S., Pingel, K., Holland, A., & Rothi, L. (2006).

A pilot study of use-dependent learning in the context ofconstraint induced language therapy. Journal of the Inter-national Neuropsychological Society, 12,843852.

Meinzer, M., Djundja, D., Barthel, G., Elbert, T., &Rockstroth, B.(2005). Long-term stability of improvedlanguage functions in chronic aphasia after constraint-induced aphasia therapy.Stroke, 36, 14621466.

Meinzer, M., Elbert, C., Wienbruch, C., Djundja, D.,

Barthel, G., & Rockstroh, B.(2004). Intensive languagetraining enhances brain plasticity in chronic aphasia. BMC

Biology, 2,19.

Nicholas, M., Obler, L., Albert, M., & Goodglass, H. (1985).Lexical retrieval in healthy aging.Cortex, 21, 595606.

Poek, K., Huber, W., & Willmes, K.(1989). Outcomes ofintensive language treatment in aphasia.Journal of Speechand Hearing Disorders, 54, 471479.

Pulvermuller, F. B., Neininger, B., Elbert, T., Mohr, B.,Rockstroh, B., Koebbel, P., & Taub, E. (2001). Constraint-induced therapy of chronic aphasia after stroke.Stroke, 32,16211626.

Pulvermuller, F., Hauk, O., Zohsel, K., Neininger, B., &

Mohr, B. (2005). Therapy-related reorganization of lan-guage in both hemispheres of patients with chronic aphasiaNeuroimage, 28,481489.

Raymer, A., Kohen, F., & Saffell, D. (2006). Computerisedtraining for impairments for word comprehension andretrieval in aphasia.Aphasiology, 20, 257268.

Raven, J. C., Court, J. H., & Raven, J. (1986). RavensColoured Progressive Matrices. London: H. K. Lewis & Co.

Robey, R. R.(1998). A meta-analysis of clinical outcomes inthe treatment of aphasia.Journal of Speech, Language, and

Hearing Research, 41, 172187.

Robey, R. R.(2004). A five-phase model for clinical-outcomesresearch.Journal of Communication Disorders, 5, 401411.



18/19

Taub, E.(1977). Movement in nonhuman primates deprivedof somatosensory feedback.Exercise and Sports SciencesReview, 4,335374.

Taub, E., Miller, N., Novack, T., & Cook, E. (1993). Tech-nique to improve chronic motor deficit after stroke. Archivesof Physical Medicine and Rehabilitation, 74, 347354.

Taub, E., Uswatte, G., King, D. K., Morris, D. M., Crago,J. E., & Chatterjee, A.(2006). A placebo controlled trial of

constraint-induced movement therapy for upper extremityafter stroke. Stroke, 37, 10451049.

Taub, E., Uswatte, G., & Piclikiti, R. (1999). Constraint-induced movement therapy: A new family of techniques withbroad application to physical rehabilitationA clinicalreview.Journal of Rehabilitation Research and Develop-ment, 36,237251.

Taub, E., & Wolf, S. (1997). Constraint-induced movementtechniques to facilitate upper extremity use in strokepatients.Topics in Stroke Rehabilitation, 3, 3861.

Wolf, S., Winstein, C. J., Miller, J., Taub, E., Uswatte, G.,Morris, D., et al. (2006). Effect of constraint-induced move-ment therapy on upper extremity function 3 to 9 monthsafter stroke: The EXCITE randomized clinical trial. Jour-nal of the American Medical Association, 296, 20953104.

World Health Organization. (2001).International Classifi-cation of Functioning, Disability and Health: ICF. Geneva,Switzerland: Author.

Received September 4, 2007

Accepted February 24, 2008

DOI: 10.1044/1092-4388(2008/07-0206)

Contact author: Tobi Frymark, National Center for Evidence-

Based Practice in Communication Disorders, American

Speech-Language-Hearing Association, 2200 Research

Boulevard, Rockville, MD 20850. E-mail: [email protected].



19/19

Date post:	03-Jun-2018
Category:	Documents
Upload:	sergio-cruzat
View:	217 times
Download:	0 times

Intensidad de Terapia y Terapia Inducida Por Restricción_ Control 2

Documents